AN OVERVIEW OF STROKE Recent perspectives DR. A.V. SRINIVASAN “Knowledge can be communicated but not Wisdom” - Hermann Hesse
Introduction Improved technology and treatment for stroke has decreased mortality and prolonged survival but disability from stroke remain Major health care concern. Although Rehabilitation is one of the oldest forms of treatment, it is least understood. Some physicians uneasiness with rehabilitation has its origin in Medical Training. Traditional Medical training emphasis on diagnosis and curative treatment. When cure is not possible patient needs Rehabilitation Therapy, Counseling and Support in the face of physical disability, feeling of failure and futility.
“The True Art of Memory is The Art of Attention” - S.JohnsonInjured Brain 25% men1. 45 85 yrs - Stroke occurs 20% women2. Guidelines for 24hrs: MandatoryLevel of Evidence Level A: Based on RCT or Meta analy. of RCT Level B: Based on Robust Experiment or Observation Studies Level C: Based on Expert opinion.
According to WHODoctor assessment of Handicap may not coincide with PatientsAssessment. Neurologist depends on physiotherapy, occupationtherapy and speech therapy in rehabilitating the stroke patients.
NEUROLOGIC PREDICTORS. Flaccid Paralysis for more than 96 hrs When tendon reflexes recover without return of voluntary movement – prognosis poor Recovery of sensory less in usual to a degree. Postion sense recovers but not pain and temperature Recovery from Dysphasia is never complete Dysarthria usual improves and Dysphagia never improves Diplopia due to brain stem is usually permanent Conjugate gaze – recovers Vertigo improves but hearing loss is permanent Pseudobulbar palsy permanent
REHABILITATION OFSTROKE Assessment of function Motor, postural, perceptual, cognitive, communication and autonomic Independence and self-care Walking dressing washing, toileting and feeding Available services Nursing Physiotherapy Occupational therapy Clinical psychology Medical social worker plus self-help groups (‘Stroke Club’)
EARLY MANAGEMENT ANDREHABILITATION Consist of1. Skin care2. IV therapy in disabled patients3. Caution due to confusion4. Auditory and visual deficit5. Splint and braces6. Complications include the following
Complications include thefollowing:A. Contractures
Complications include thefollowing:b. Treatment of Spasticity TREATMENT MODALITIES FOR SPASTICITY Surgery Nerve Blocks Motor Point Blocks Drugs: Dantrolene, Baclofen, Diazepam Muscle Stretching Program Prevention of Nociception
Complications include thefollowing:c. Reflex sympathetic Dystrophyd. Physiological Deconditioning. PHYSIOLOGICAL DECONDITIONING Loss of Normal Postural Reflexes Increased Resting Pulse Rate Catabolic Nutritional State- Psychological Depression Lower Vital Capacity Slowing of GI Tract Venous Stasis Urinary Stasis
Complications include thefollowing:e. Swallowing disordersf. CVD and Heterotrophic ossification 7. Psychological factors
FACTORS GOVERNING THEOUTCOME OF STROKEREHAB. Good outcome – Mild to moderate neurologic damage with mild moderate paresis not associated with sensory or visual problems Patients not demented or depressed
FACTORS GOVERNING THEOUTCOME OF STROKEREHAB. Walking 150 feet without assistances (Goal ) Motor alone – 0.9 Motor Sensory Visual – 0.5 Barthal index score – 95 normal • Motor alone - 0.6 • Motor Sensory Visual – 0.5
FACTORS GOVERNING THEOUTCOME OF STROKEREHAB. Motor deficits alone reach their goals within 12 weeks Framinham study – recovery from stroke 3 months Adams – recovery from stroke 2 years
FUTURE TRENDS IN REHABILITATION(Sensory Modulation) Anatomical Principles Somatosensory System Limbic System Visual System Phantom Experiences The man who missed his foot for penis Gaze Tinnitus Ear Lobe stimulation produces as an eroatic sensation in nipple Phantom Pain
FUTURE TRENDS IN REHABILITATION(Sensory Modulation) Role of Parietal Lobe Clinical Implications Synesthesia - Virtual reality box Allesthesia - Extinction of referred sensation Caloric test - Disappearance of Anosognosia
SUMMARY The goal of rehabilitation is to permit a return to function. In pursuit of this goal, proper management of secondary disabilities is essential. Clinical objectives include: prevention of contractures, retardation of deconditioning, maximization of nutritional status, optimal treatment of associated medical problems, and providing appropriate psychological support to family and patients.
1. History And Examination a. Stroke clerking Performa (1994) R.C.P. 1. Improved patient Assessment 2. Improved Management - not clear 3. Improved outcome - not clear b. Examination 1. Secure Diag of Stroke 2. Specify Impairment 3. Identify sub type of Ischemic stroke “ We Sometimes think we have forgotten something when in fact we never really learned it in the first place” Imp.Your Memory Skills
Through Action You Create your Own Education - D.B. ELLIS Guide: 3 (B) - CPR Impaired Consciousness - From Stroke Resuscitation is rarely successful Schneider 1993 Guide: 4(B) Investigations:(Sagar 1995)- 435 PTS) Chest x-ray 16% ABN Only 4% change clinical management Order x-ray chest if WT Loss or chest symptoms present
Guide 5: (B) ECG: Cardiac cause of Death (30 days) Ebrahim 1990. All conscious patients to have ECG Guide 6: (C) CT: Routine CT Head is a Intell lazy approach King’s fund forum(1988) gives useful framework Weir 1994 Clinical scoring cannot distinguish Do CT if a) Uncertainty of Stroke b) If Anticoagulation or Anti Platelet treatment contemplated
Guide 7:(B) M.R.I. Moha 1995, - Unclear for Implications for clinical practice No Routine MRI indication in Acute StrokeWhatever the Mind can conceive and Believe, the mind can Achieve Napoleon Hill
Imagination is moreImportant than Knowledge Guide 8: (B) ECHO no Routine Echo in Acute Stroke TOE Vs. TTE Amer Heart Asson (1997) - same conclusion Yield is very low. (Leung 1993; Chambors 1997) Only when ABN ECGS - change clinical management
Guide 9: (A) - Dopp scan for selected PTS: 80% > more benefits from Endarterectomy Minor stroke -No disability Subst Storke -Good recovery do doppler Medically fit
Guide 10: (B) Management: Fever (Worst Prog.) Reith 1996 Hypoxia ( Moroney 1996) - Exac. by seizures Pneumonia and Arrythmias - Worst outcome Hyperbaric O ineffective (Nighoghossaln 2 1995) Haemodilut. Plasm Expanders; venesection No evidence for efficacy (As plund - 1997) Check ABG only if Hypoxia suspected.
Guide 11: (A) Steroids and Hyperosmolar agents Unproven treatment - should not be used Tumor oedma responds but not cytotoxic stroke oedma qialbash 1997 - No effect on survival or improv. In funct. Outcome Manntol - (Boysen 1997) - short term effective statistically in conclusiveYou are what you think and notwhat you think you are Annoymous
We learn by thinking and the quality of the learningoutcome is determined by the quality of ourthoughts R.B. Schmeck Guide 12: (B) - Blood Pressure Defer - acute reduction of BP - 10 days unless HT Encephalopathy or adrtic dissection present Moris 1997 - Increase BP - falls in 10 days UK - 5mm in D.B.P. 1/3 storke - Low BP prompt correct of hypovoll. and withdrawal of hypotonic drugs Collins 1994 - HT - Prim. stroke prevent Neal 1996 (Current RCT) - HTs in stroke survivors -study needed
Guide 13: (A/B) - AF AF / ISCH Stroke/ Mild disability - warfarin after 48 Hrs (Longer for larger) Aspirin for others EAFT 1995 Less than 2 PT - No effect SPAF 1996 > 5 - Bleeding
Guide 14:(B/C) - Blood sugar Weir (1997) > 8 mm d/Lit - Poor outcome Acute MI + 11 mm d/Lit - Intensive Insulin - improved (Malmberg 1997)A great many people think they arethinking when they are merely rearranging their prejudices W. James
Many Ideas grow better when transplanted intoanother mind than in the one where they sprangUP O.W. Holmos Guide 15: (A) Cholesterol Prosp. Study collob.: 1993 - Epidem study do not support Blaun 1997: Metranauetic - Chollest & statin 30% decrease - stroke in CAHD patients. Sacks 1996 - Tot chol: decrease to 4.8 mmol/Lit benefits
Guide 16: (A/C) Deep vein thrombosis Kalra 1995 - 10 days - stroke Pts - 50% Sandercock 1993 - Pul embol 6-16% only Ist 1997 - 5000 IV or 12500 twice daily - Hemorrage greater Gradual stocking value - useful in Surg - pts but its value not evaluated - (Wells 1994) Use with caution - if periph artery insuf. is present hence do not use heparin on stockings.
Guide 17: (A/B) Pressure sure Event health care (1995) specialised low pressure mattress systems to be used than stand Hospital - mattressEvery discovery contains anirrational element or 4 creativeintuition Khrl Popper
I have never let my Medical schooling interfere withmy education Mark Twain Manag of infarction Guide 18: (A) • Aspirin 75 - 150 /Day • 3 yrs 40% reduces of vascular events in 1000 pts (APTC - 1994) • Stroke sub type value ? (TACI, PACI, LACI, POCI) • Dienners - 1996, synergy possibel with clopidogrel ticlopidine etc.
Anti Coagulation Warfarin - AF In sinus rhythm - uncertain Spirit 1997 low dose ABP + Warfarin in TIA & Minorstorke - Stopped of HE Heparin (IST 1997) - Signif. reduction in early death (12 fewor in 1000) not better than aspirin So avoid Heparin (A)
Thrombolysis (A) Warlow 1997 - Uncertain clinical benefit at the expense of greater hazard avoid - thrombolysisWhen they tell you to grow up,they mean stop growing P. Diccaso
A (Neurologist’s) life is like a piece of paper onwhich everyone who passes by leaves animpression - Chines proverb Guide 20: (I) Hemorrhage Hankey and hon 1997: Supra tentorial evacuation for ICH is controversial - Avoid Infra tentorial - Yes Main Indication - Deteriorating or depressed consciousness
2 2 4 P ts Guide 21 : Ventilation 131 I n t u b a tio n 93 N o t In tu b -Decreased level of consciousness - increased 6 4 D is c h a r 6 7 D ie d mortality and poor final3 4 R e d ta g 2 1 d is c h t o n ver h om e 8 D is c fo r p a llim a 1 D is c H om e outcome - Absent pupillary light 3 D ie d 7 D ie d 3 D ie d responses - poor prognosisA medical school should notbe a preparation for life. Aschool should be life
“By the deficits we may know the talentsBy the exception we may discern rulesBy studying the pathology,We construct the model of healthAnd tools we need to affect our own life mould our destiny,Change ourselves and our societyIn ways that as yet we can only imagine” - Lawrence Miller
STROKE-TO-DEMENTIA(Dr. A.V. Srinivasan, Dr. S. Balasubramanian, Dr. R. Sowntharya, Dr. S. Rajesh) Dr. A. V. Srinivasan Addl. Prof. Of Neurology Institute of Neurology, Chennai.
Pathogenesis of dementiadue to SIVD1. Lacunar hypothesis2. Binswanger’s subtype of SIVD3. VaD with coexisting Alzheimer’s disease Expert is one who think to his chosen mode of ignorance
Two diverging/converging pathways associated with SIVDRisk factor CVD Ischemic Brain injury MRI lesion Clinical syndromeHTNArteriosclerosis 1. occlusion complete infarct lacune lacunnar stateArteriosclerosis 2. Hypoperfusion incomplete infarct WHSM Bingswanger syndrome Experience can be defined as yesterday’s answer to today’s problems
Clinical syndromes1. Lacunar state --- 85%2. Strategic infarct dementia(e.g. thalamic dementia) --- unknown %3. Binswanger’s syndrome --- 10 – 15% Take time to think; it is the source of powerTake time to read; it is the foundation of wisdom Take time to work; it the price of success
Features suggestive of vascular dementiaFrom the history Onset associated with a stroke Improvement following acute event Abrupt onsetFrom the exam Findings typical of stroke e.g., hemiparesis, hemianopiaFrom imaging Infarct(s) above the tentorium Every thing should be made as simple as possible; but not simpler
Categories of vascular Dementia Category Clinical presentationLacunar infarctions Progressive dementia, focal deficits, or apathetic, frontal-lobe-like syndrome, may have no stroke historySingle strategic Sudden onset aphasia, agnosia,infarctions anterograde amnesia, frontal lobe syndromeMultiple infarctions Step-wise appearance of cognitive & motor deficitsMixed AD – VaD Progressive dementia with remote or concurrent history of strokeWhite matter Dementia, apathy, agitation, bilateralinfarctions cortico-spinal/bulbar signs(Binswanger’sdisease)
NINDS-AIREN criteria for VaDProbable vascular dementia : cognitive decline from a previously higher level in three areas of function including memory; evidence of cerebrovascular disease by neurologic exam and neuroimaging; onset of dementia either abruptly or within 3 months of a recognized stroke.Possible vascular dementia : Dementia in the absence of either neuroimaging evidence of infarction or in the absence of a clear temporal relationships between dementia and stroke. NATURE, TIME AND PATIENCE are the 3 great physicians
NINDS-AIREN criteria for VaDcontd…AD with cerebrovascular disease : Patients with possible AD who have imaging evidence for infarction, or clinical history of stroke, both of which appear incidental by clinical judgementDefinite vascular dementia : Probable vascular dementia plus histopathological evidence of infarction in the absence of other histological markers of dementia (e.g., plaques, tangles, pick bodies, etc.,) Truth comes out of error sooner than that of confusion
Diagnostic criteria1. Hachinski’s ischemic score2. DSM IV criteria3. ADDTC criteria4. NINDS – AIREN criteria5. Binswanger’s criteria Opinion is ultimately determined by the feelings and not by the intellect
Short comings1. Not interchangeable hence four fold rise in frequency2. DSM IV R most liberal3. NINDS- AIREN criteria conservative4. Gold standard for VaD (pathological definition difficult)5. Most of the criteria failed to distinguish between small and large vessel subtypes “HealthyMind and Healthyexpression of Emotion go hand in Hand”
Diagnosis and prognosisRisk factors Modifiable Non-modifiable Hypertension Age Hyperglycemia Gender Race Heredity Discipline Weighs ounces R egret weighs Tons
Diagnosis and prognosiscontd….Vascular phenotype : “CVD” Arteriosclerosis Amyloid angiopathy Other small vessel disease“Y have got to be before y can do ou ouand do before y can have” ou
Diagnosis and prognosis contd…. Vascular Mechanism of Pathological distribution Brain injury phenotype “Infarct”Single artery Acute ischemia Multiple lacunarSmall arteriole infarctsSingle artery Acute ischemia Single strategically placed lacunar infarctBorder zone Chronic White matterSmall arteriole hypo perfusion demyelination and axonal loss
Diagnosis and prognosis contd….Neuro imaging phenotype CT lucency (lacunes and leukoariosis) MRI hyper intensity (lacunes and WMSH)A true com itm is a heart felt prom to m ent iseyourself fromwhich y will not back down - ou D. Mcnally
Prognosis1. Risk factors Advanced age Education Develops dementia Lacunar subtype following ischemic Lt. Hemisphere CVA stroke Non white “ Fools Adm but of m of sense approve” ire en - A. Pope
Prognosis contd….2. In Lacunar stroke - Leukoariosis is a poor prognosis3. Recurrence of strokeHence Atrophy cognitive impairment WMSH are inter related in SIVD “ Social Isolation is in itself a pathogenic Factor for disease production”
Prevention & TreatmentPrimary preventionControl of risk factors in mid lifea. Framingham Heart Studyb. HASSc. ARICd. Systolic hypertension in Europe double blind trial At twenty the will rules At thirty the intellect At forty Judgment
Prevention & Treatment contd…Secondary preventionBelow 135 mm of Hg cognitive impairment Presence of lacunes and white matter changes may be used as a marker for high risk group Little is known – for effectiveness in other risk factorsA woman’s desire for revenge outlasts all her other emotions
Prevention & Treatment contd…Anti dementia drug trials (not based on subtype of VaD)Alkaloid derivatives(hydergine or nicergoline)PentoxyfyllinePiracetam Modest benefitMemantineDonepezilGingko biloba Thought is the labour of the intellect Reverie is its pleasure
Role of RIVASTIGMINE in SIVDNo.of patients : 10Age group : 50 – 80 yearsFemale : 4Male : 6Most of them had diabetes and hypertensionNot based on subtype of VaD30% showed remarkable cognitive, curative and affective deficitFuture study needed “ He who cannot forgive others destroy the bridge s over which he him m pass” - Annoy self ust
Strategies to prevent – STROKE-TO-DEMENTIA Treat hypertension optimally Treat diabetes Control hyperlipidaemia Persuade patients to cease smoking and decrease alcohol intake Prescribe anticoagulants for atrial fibrillation Provide antiplatelet therapy for high risk patients A open foe may prove a curse ; but a pretended friend is worse
Strategies to prevent – STROKE-TO-DEMENTIA contd… Perform carotid endarterectomy for severe (>70%) carotid stenosis Use dietary control for diabetes, obesity and hyperlipidaemia Recommend lifestyle changes (e.g., weight loss, exercise, reduce stress, decrease salt intake) Intervene early for stroke and transient ischemic attacks with neuroprotective agents (e.g., propentofylline, calcium channel antagosists, N-methyl-D-aspartate receptor antagonists, antioxidants) Provide intensive rehabilitation after stroke
READ not to contradict or confuteNor to Believe and Take for Grantedbut TO WEIGH AND CONSIDERTHANK YOU